Panel on Primary Health Care in the Americas:Lessons Learned Over 25 Years and Future Challenges

It is a great pleasure for me to be here at PAHO to review with this distinguished group of panellists the lessons learned in Primary Health Care (PHC) in the past 25 years and to look ahead to future challenges in promoting Health for All in the region of the Americas.

I used to be a frequent visitor to PAHO and to Latin America and the Caribbean in the 1980s when I served first as the UNICEF Representative in Haiti and later, as Chief of the Americas section at UNICEF’s Programme Division in New York. I remember vividly the difficult economic context, with the debt crisis and hyper-inflation that afflicted the region, turning the 1980s into a “lost decade” for development in Latin America.

So the health challenges we faced in this region during the first decade following the Alma Ata Declaration were tough. But there were also some shining moments: UNICEF and PAHO worked together to develop “health as a bridge to peace” projects in conflict-ridden Central America. We were great partners in the polio eradication campaign that made the Americas the first polio-free region in the world a decade ago.

The Child Survival Revolution that UNICEF promoted as the cutting edge of Primary Health Care originated in this region – with National Immunization Days in Colombia, the Pastoral do Crianca in Brazil, the pioneering work in nutrition by INCAP out of Guatemala and the “Days of Tranquillity” that literally stopped the war to allow children to be vaccinated in El Salvador.

The world was a very different place in September 1978, when 134 ministers of health, and our predecessors, the leaders of WHO and UNICEF, met in Alma Ata, and launched the revolutionary concept of Primary Health Care.

Looking back, the concept of PHC that came out of Alma Ata was a bold attempt to redefine health by the people and for the the people. Its aim was to transform “Medical Treatment for Some” into “Health for All”.

Alma Ata sought to bring the benefits of modern medicine, science and technology to the doorsteps of even the poorest families of the poorest countries. It set the stage for ushering in what we would call today the rights-based approach to health care.

“The people have the right and duty to participate individually and collectively in the planning and implementation of their health care” said article 4 of the Declaration of Alma Ata. Primary Health Care, it argued, was “essential health care made universally available to individuals and families in the communities by means acceptable to them, through their full participation, and at a cost that the community and country can afford”.

Some of the intellectual contribution for the founding principles of PHC had been inspired by experiences in this region, especially those of health care systems in Cuba, Venezuela and Chile in the 1970s.

The concept of PHC paved the way for many other revolutionary ideas that later became common wisdom in international development, including Basic Services, Education for All, and Health for All.

But after a very promising start, PHC had lost some momentum at the beginning of the 1980s, when the debt crisis and the onset of structural adjustment programmes had sapped the vitality of this region’s health systems and social development.

It took the Child Survival and Development Revolution promoted by UNICEF’s Jim Grant, and later embraced by Halfdan Mahler of WHO, and leaders like Carlyle Guerra de Macedo and Ciro de Quadros of PAHO to give a new boost to PHC.

Though meant to be multi-sectoral, in the early years after Alma Ata, primary health care was still generally seen as a health sector concern. What the Child Survival and Development Revolution did in the 1980s, was to put health issues firmly onto the world’s political and social agenda, cultivating ownership by mayors and governors, parliamentarians and civil society activists, the media and the academia.

Inverting the “Health for All” motto to “ALL for Health”, the Child Survival and Development Revolution saw everyone, from film stars to schoolteachers, heads of religious organizations to heads of states, actively involved in promoting ORT, immunization and other health and nutrition interventions.

Inspired by this, UNICEF helped convene the World Summit for Children in 1990. It adopted an ambitious agenda for accelerating child survival and development, with public health and nutrition actions at its core. In the true spirit of PHC, it called for the active participation by all key sectors and actors of society.

The Summit adopted a goal-oriented approach, bringing the international community to agreement on a common development agenda with clear targets and milestones, especially in the area of health. Indeed many of today’s Millennium Development Goals have their origins in the health related goals of the World Summit for Children.

In May 2002, world leaders convened again at the UN General Assembly Special Session on Children, to review the progress made on the goals and targets of the World Summit for Children over the past decade. Six goals were identified for which notable success had been achieved. All of them were in the field of health: immunization, reduction of deaths due to diarrhoea and neonatal tetanus, vitamin A deficiency, iodine deficiency and progress towards eradication of polio and guinea worm diseases.

Good surveillance, monitoring and evaluation were instrumental in accelerating progress in programme implementation and documentation of lessons learned. This is an area in which the Americas region performed very well, with ministerial level meetings held every two years to document achievements. The Ibero-American Summits and the CARICOM summits too have taken up the issues of child health and well-being as a regular item on their agenda.

Although there is still much to be done to realize the vision of Alma Ata, the Americas region has reasons to be proud of its achievements.

The new PAHO report on Moving Towards a New Century of Health in the Americas issued two days ago, speaks of dramatic improvements in health in the Americas.

A study commissioned for the 10th Ibero-American Summit of Heads of State and Governments by UNICEF, ECLAC, PAHO and others and entitled “Building Equity from the Beginning: the Children and Adolescents of Ibero-America” confirms the same findings.

This region has made impressive achievements in reducing infant mortality, maternal mortality and malnutrition, and in increasing life expectancy, literacy and access to water and sanitation – all tangible measures of improved health.

As we look ahead, I see 5 major challenges if we are to fully realize the vision of PHC in the coming decade in the Americas and in the world:

The Challenge of mobilizing “All for Health”

The Challenge of Global Interdependence

The Challenge of Going to Scale

The Challenge of Mobilizing Resources, and

The Challenge of Leadership

Let me share with you some of the specifics under each of these 5 challenges:

1. The Challenge of Mobilising “All for Health”

It is often said that health is too important to be left entirely to the care of medical professionals. Health establishments, whether hospitals, clinics or Ministries of Health, all play an important role in combating diseases and promoting health. But their effectiveness is greatly enhanced if they can mobilise support from sectors outside health.

From the point of view of child health, the number one health worker is the mother. The more we can do to empower her with basic knowledge, information and skills in good infant feeding practices, care and stimulation of the young child, hygiene and sanitation, better birth spacing, etc. the better the health outcomes of her child. Good maternal health and nutrition too are, of course, of paramount importance.

One of the best ways to promote this is actually through action in the education sector. As we know, girls’ education is probably the most effective of all health interventions. An educated girl marries later. She can better protect herself from diseases, including HIV/AIDS. She has reduced fertility, lower infant and maternal mortality. Her children are likely to be better nourished and healthier. They are more likely to go to school and perform better. And as they become adults, they help break the intergenerational cycle of ill health and poverty.

School teachers are potentially great health workers. Most children spend many years as a captive audience of their teachers. If teachers had the basic knowledge of nutrition, hygiene and sanitation, and if they were empowered to impart such knowledge to their students, they could make an enormous contribution in bringing about good health outcomes.

It is said that the greatest reductions in infant and child mortality in the 19th century in Europe were attributable, not to medical breakthroughs but to dramatic progress in potable water and sanitation. Collaboration with actors in the water sector can therefore produce great results in promoting good health.

And in today’s world, mass media and communication can be a great provider of good health information or a promoter of unhealthy life-styles. The communications media, both public and private, can therefore be the greatest ally of ministries of health in their mission of health promotion.

So let us mobilize “all for health”, not just promote “health for all”

2. The Challenge of Global Interdependence:

We cannot be healthy in an unhealthy world. Unlike people, diseases do not need a passport or visa to travel.

We must therefore promote international cooperation to combat diseases and to promote health as global public goods.

Programmes to eradicate or eliminate polio and measles, to fight HIV/AIDS, malaria and tuberculosis, and to promote epidemiological surveillance must increasingly be considered global public goods.

In this age of globalization and massive movements of people across borders, diseases can be weapons of mass destruction, but health can also be a bridge to peace.

3. The Challenge of Going to Scale:

The health development map of the world is littered with small scale pilot studies and demonstration projects. While some of these are useful for innovation and replication, others tend to be of greater interest and benefit to researchers, donors and their local counterparts than to the intended beneficiaries.

To be really useful, development programmes should attempt to take action on a scale commensurate with the problems that they are trying to tackle.

For most of the major causes of mortality and morbidity affecting children and women in developing countries, we do have proven, cost-effective interventions. Examples abound in the recent Lancet articles on child survival. The challenge is to take such interventions to scale.

Fortunately, we already have globally approved goals and targets, and agreed strategies. But we need to scale up actions with simple and focused plans, strong partnerships, competent and motivated human resources, essential supplies, strong monitoring and evaluation, and sufficient funds.

4. The Challenge of Finance:

The WHO Commission on Macroeconomics and Health estimates that the financial resources required for a set of essential interventions against infectious diseases and nutritional deficiencies that could potentially save 8 million lives per year in low income countries would cost around $34 per person per year.

The total additional resources needed for low income countries would amount to an additional 1 to 2 percent of their GNP, and for the donor community an additional 0.1 percent of their GNP in the form of ODA. These amounts are certainly affordable for both developing countries and for donors.

Given the extraordinary benefits of investment in health not only in terms of lives saved and sicknesses averted, but of gains in productivity, there are few other investments that yield comparable benefits in achieving the broader millennium development goal of poverty eradication.

The public sector alone need not bear the burden of investment in health. In recent years we have seen laudable examples of generous corporate contribution to such initiatives as the Global Alliance for Vaccines and Immunization (GAVI), the Global Fund for AIDS, Tuberculosis and Malaria (GFATM), and to the development efforts of UNICEF, WHO and others by private sector donors such as the Bill and Melinda Gates Foundation, the Ted Turner-funded UN Foundation, Rotary International and the Kiwanis.

The pharmaceutical industry can also be a more enlightened partner in such public health efforts. The public sector can encourage this by providing tax and other incentives.

5. The Challenge of Leadership:

Finally, we need strong leadership at the local, national and international level to promote health for all.

Health issues are now commanding the interest and support of many world leaders ranging from the UN Secretary-General Kofi Annan, to Bill Gates and Bono. I know WHO/PAHO, UNICEF, UNFPA, the World Bank, the Inter-American Development Bank and others are all deeply committed to giving health a high priority. If collectively we can mobilize leadership at the highest levels of governments, civil society and the private sector, health for all need not be a dream delayed for too long.

Given its past record, and future potential, we look to PAHO to provide a strong leadership in pursuing the vision of Alma Ata, and we count on the Americas region to once again set an example for the rest of the world to follow.